The diagnosis of chronic radiation enteritis may be difficult to make. Clinically and radiologically recurrent tumor needs to be ruled out. Because of the possible latency of the illness, it is essential that the physician obtain a detailed history of the patient's radiation therapy course. It is often advisable to include the radiation therapy physician in the continued management of the patient's care.
Medical management of the patient's symptoms (which are similar to symptoms of acute radiation enteritis) is indicated, with surgical management reserved for severe damage.[Level of evidence: I] Fewer than 2% of the 5% to 15% of patients who received abdominal or pelvic radiation will require surgical intervention.
The timing and choice of surgical techniques remains somewhat controversial. A lower operative mortality (21% vs. 10%) and incidence of anatomic dehiscence (36% vs. 6%) have been reported with intestinal bypass as compared with resection.[Level of evidence: II] Those who favor resection point out that the removal of diseased bowel decreases the mortality rate for resection and is comparable to the bypass procedure. All agree that simple lysis of adhesions is inadequate and that fistulas require bypass.
Surgery should be undertaken only after careful assessment of the patient's clinical condition and extent of radiation damage because wound healing is often delayed, necessitating prolonged parenteral feeding after surgery. Even after apparently successful operations, symptoms may persist in a significant proportion of patients.
Treatment techniques that can minimize the risk of severe radiation enteritis include the following:
- Radiation therapy techniques, including the following:
- The use of a three- or four-field technique (as opposed to a two-field technique) to minimize the amount of small bowel exposed to treatment.
- The treatment of the patient in a physical position that will aid in removing as much small bowel from the treatment field as possible (e.g., treating a patient with a full bladder each day to aid in pushing the small bowel up and out of the pelvis when pelvic radiation is given).
- Daily treatment of all fields, resulting in a lower integral dose and more homogenous dose distribution.
- Use of computerized radiation dosimetry to best design the treatment plan and the use of high-energy treatment machines such as linear accelerators that deliver a high dose-to-tumor volume while sparing the normal structures.
- Surgery. Placing clips in high-risk areas to better define the location or former location of the tumor and aid in radiation treatment planning.
- Modification of treatment sequencing. An area for exploration is the sequencing of radiation, chemotherapy, and surgery and its influence on the severity of enteritis.
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